Patient Safety Event Reviews

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Patient safety event reviews and Section 51 of the BC Evidence Act

If a patient experiences a “patient safety event” (an event or circumstance which may have resulted, or did result, in unnecessary harm to a patient while under our care), the Provincial Health Services Authority (PHSA) does everything possible to learn from the event. One of the things we do is conduct a quality patient safety event care review.

In healthcare, when a patient safety event occurs the goal is immediate management, disclosure and analysis of the event through a structured process, focused on system improvement, that aims to identify what happened, how and why it happened, whether there are any ways to reduce the risk of recurrence and make care safer. PHSA conducts patient safety event reviews in accordance with Section 51 of the
BC Evidence Act.

What is Section 51 of the BC Evidence Act?

Section 51 of the BC Evidence Act prohibits the disclosure of information and documentation collected as part of a hospital’s quality of care review. All records, summaries, reports and opinions prepared for a designated quality improvement committee during the quality review are prohibited from being disclosed externally. As well, documents prepared for a quality review committee or by the review committee for the hospital’s board cannot be admitted into evidence in civil proceedings, nor can witnesses or members of the committee give evidence about the review.

Rationale for Section 51 of the Evidence Act

Section 51 of the Evidence Act is intended to promote full, open and candid discussions amongst health care professionals with the goal of ensuring the most opportunities for improving care will be discovered. Section 51 is intended to foster full participation and the best process for learning from the patient safety event. Quality reviews generate recommendations for potential improvements that may benefit future patients. For example, policy changes may be recommended, or specific education sessions for healthcare professionals.

Patient safety event reviews do not preclude health-care professionals from cooperating in other reviews by outside investigative bodies, such as the police or regulators, nor do they shield health care professionals or PHSA from potential civil suits.

Disclosure of information following a Section 51 review

A patient may be informed about the following after a section 51 review:

the fact that a quality patient safety event review was conducted and when it occurred;

any information contained in the patient chart;

any other clinical factual information contained in documentation which was not prepared for the review; and

medical
facts.

All records created during the proceedings of a review, as well as the opinions expressed by the participants in the review, the findings and conclusions of the review committee (subject to what is set out in the paragraphs below) cannot be disclosed beyond the health authority board of directors and, in some instances, health care professional governing bodies.

“De-identified” information (information that has confidential information removed from it) and learnings coming out of a patient safety event review can also be used for education purposes. They can be shared broadly among other health authorities and health professionals to improve patient safety throughout the entire health care system.

Other than as set out above, once a review is commenced under Section 51, it is not lawful for any other information to be disclosed by PHSA or any participant in the review.